Online Registration Form

• Read our TERMS & CONDITIONS.
• Please fill this form out as completely as possible.
• Be sure that the parent phone number and email you give us is correct in case we need to verify your information.
• If you would like to register more than one student please register them separately.

All fields are REQUIRED unless noted as OPTIONAL. Required fields #15 & #16 must at least have "N/A" if no information is available.

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Section 1: General Information

1. Student Name:
(first and last name)

2. Birth Date:
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980

3. Address:

4. Apt. #:
OPTIONAL

5. City:

6. State:

7. Zip Code:

8. Grade:
K 1 2 3 4 5 6 7 8 9 10 11 12 (2007-08 school year)

9. School:

10. Gender:
Male Female

11. Shirt Size:
Small Medium Large XLarge

12. Height:
(inches)

13. Weight:
(lbs)

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Section 2: Medical Information

14. Last Tetanus Booster:
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980

15. Allergies (type "N/A" if none):

16. Medications (type "N/A" if none):

17. Physician:

18. Physician Phone:

19. Insurance Provider:

20. Insurance Provider Phone:

21. Insurance Group Number or Subscriber ID:

22. Insurance Card Number:

23. Primary Card Holder:

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Section 3: Parent / Guardian Information

24. Parent Name:

25. Home Phone:

26. Work Phone:
OPTIONAL

27. Email:

28. Emergency Contact:

29. Emergency Contact Phone:

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Section 4: Student Essay

The student must answer the following question in 250 words or less. Submitted registrations with invalid essays will not be considered.

What does aviation mean to you? (max: 250 words)

By submitting this registration you ACCEPT & AGREE to our Terms and Conditions. DO NOT submit this registration if you disagree with our policies.